Medica Surgical Nursing: Chapter 1
Terms
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- THE NURSING PROCESS (ADPIE)
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THE NURSING PROCESS (ADPIE)
A = Assessment
D = Diagnoses
P = Planning
I = Implementation
E = Evaluation - SUBJECTIVE vs. OBJECTIVE DATA
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SUBJECTIVE vs. OBJECTIVE DATA
SUBJECTIVE DATA
- symptoms
- patient's feelings, or individual perception of problems and needs
OBJECTIVE DATA
- signs
- physical exam, laboratory findings, direct observation - DIAGNOSTIC STATEMENT (PES)
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DIAGNOSTIC STATEMENT
(PES Format)
P = Problem
E = Etiology
S = Signs & Symptoms - OPEN ENDED Q's vs. CLOSE ENDED Q's
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OPEN ENDED Q's - general info
- not useful when interviewing a confused pt/emergent situation
CLOSE ENDED Q's - fact finding
- focus on ceratin area/concern to elicit infor quickly & efficiently - PHYSICAL EXAMINATION TECHNIQUES (IPPAM)
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PHYSICAL EXAMINATION TECHNIQUES (IPPAM)
1. Inspection
2. Palpation
3. Percussion
4. Auscultaion
5. Measurement -
HEAD EXAMINATION
(HEENT) -
HEAD EXAMINATION
(HEENT)
H = Head... Condition of hair and scalp. Symmetry of face
E = Eyes Do conjunctiva and sclera appear normal in color and hydration? Are pupils PERLA?
E = Ears... Hearing aids, impairment, pain, drainage
N = Nose... Congestion, drainage, sense of smell
T = Dentures, musous membranes pink & hydrated, odor, hygiene, JVD, tracheal alignment, retractions - 3 TYPES OF NORMAL BREATH SOUNDS
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3 TYPES OF NORMAL BREATH SOUNDS
1. Bronchial (Tracheal/Tubular)
2. Bronchovesicular
3. Vesicular - 4 TYPES OF ABNORMAL/ADVENTITIOUS LUNG SOUNDS
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4 TYPES OF ABNORMAL/ADVENTITIOUS LUNG SOUNDS
1. Crackles (rales)- simulated b rolling a lock of hair near the ear between two fingers. Best heard on inspiration in the lower bases. Not relieved by coughing.
2. Ronchi - Coarse, arsh, loud gurgling. Best heard on expiration over bronchi and trachea. May be relieved b coughing.
3. Wheezes: high pitched squeeky sound. Best heard on expiration over all ling fields. Unrelieved by coughing.
4. Stridor - Harsh, high pitched sound heard during both inspiration and expiraion. Can easily be heard without a stethoscpoe and is inidcative of a progressive narrowing of the upper airway. Can be an indication of upper airway obstruction and can be life threatening, requiring immediate attention. -
EXAMINATION OF THE ABDOMEN
(IAPP) -
EXAMINATION OF THE ABDOMEN
(IAPP)- look, listen and feel
1. Inspect - skin distention, scars, obesity, herniations, etc.
2. Auscultate - BS -> hypo: every minute; normal: every 15-20 sec; hyper: about every 3 sec
3. Percuss
Dullness - solid organ
Tympany - air filled, bowels
Resonance - lungs
Flatness - muscle, bone
4. Palpate - pulsation, masses, tenderness, rigidity. When assessing pain, always work from area of least pain towads area of most pain. - PQRST
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PQRST
P = Provokes/point
Q = Quality
R = Radiation/relief
S = Severity/s&s
T = Time/onset - COLDERRA
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COLDERRA
C = Characteristics
O = Onset
L = Location
D = Duration
E = Exacerbation
R = Radiation
R = Relief
A = Associated s&s - NEUROVASCULAR STATUS: Checking the 6 P's
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NEUROVASCULAR STATUS: Checking the 6 P's
1. Pain
2. Pallor
3. Polar
4. Paresthesia
5. Paralysis
6. Pulse -
Normal ARTERIAL BLOOD GAS (ABG) values for adults
pH
pCO2
HCO3
pO2
SaO2
Anion gap Base excess -
Normal ARTERIAL BLOOD GAS (ABG) values for adults
pH (arterial) = 7.35 - 7.45
pCO2 (mmHg) = 35 - 45
HCO3 (mEq/L) = 22 - 26
pO2 (mmHg) = 75 - 100
SaO2 (%) = 95 100
Anion gap Base excess = 10 - 12 mEq/L; (+/- 2mEq/L) -
ELECTROLYTES
Sodium (Na)
Potassium (K)
CO2 combining power
Calcium, total (Ca)
Calcium, ionized
Magnesium (Mg) -
ELECTROLYTES
Sodium (Na) = 135 - 145 mEq/L
Potassium (K) = 3.5 - 5.1
CO2 combining power = 22-30mEq/L
Calcium, total (Ca) = 4.5 - 5.5 mEq/L
Calcium, ionized = 2.2 - 2.5 mEq/L
Magnesium (Mg) 1.5 - 2.5 mEq/L -
GLUCOSE
Fasting (FNS)
(serum, plasma)
(whole blood);
(elderly)
panic values:
Fingerstick glucose (self monitoring device) -
GLUCOSE
Fasting (FNS) 70 - 110mg/dl (serum, plasma)
60 - 100mg/dl (whole blood);
70 - 120mg/dl (elderly)
panic values: <40 or >700mg/dl
Fingerstick glucose (self monitoring device) 60 - 100mg/dl -
HEMATOLOGY
WBC
RBC (men),(women)
Hemoglobin (Hgb) (men),(women)
Hematocrit (Hct)(men),(women)
Platelet count:
Neutrophils: (absolute count) -
HEMATOLOGY
WBC = 5,000 - 10,000, 4,500-11,500/mm3
RBC = 4.5 - 5.3 million or mm3 (men), 4.1-5.1 milliom or mm3 (women)
Hemoglobin (Hgb) 13.0-18.0 g/100ml (men), 12-16g/100ml (women)
Hematocrit (Hct)37-49% (men), 36-46% (women)
Platelet count: 150,000-400,000/mm3
Neutrophils: 1,935-7,942 (absolute count) or 45-75% - ALBUMIN (Description)
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ALBUMIN
- component of protein synthesized by the liver
- responsible for increasing osmotic pressure to maintain intravascular fluid retention and transportation of hormones, fatty acids, bilirubin, meds, & substances insoluble in water; a decrease in albumin will cause fluid shifts from the blood vessels into the tissues causing edema formation